Healthcare Provider Details

I. General information

NPI: 1962209056
Provider Name (Legal Business Name): REAGAN WALKER SANFORD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 GREEN ACRES RD # 101
FORT WALTON BEACH FL
32547-1170
US

IV. Provider business mailing address

319 GREEN ACRES RD # 101
FORT WALTON BEACH FL
32547-1170
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-7681
  • Fax:
Mailing address:
  • Phone: 850-243-7681
  • Fax: 850-243-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6546
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA912410
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: